Why Tuesday?

Tuesday, September 29, 2009

My mother insists on diagnosing herself. Truth be told, she is not alone. Now, I am a sincere fan of technology. I am not one of those Luddites who feel that we've "lost our way of communicating with each other" due to the "mass of media" so to speak. in fact just last night, I used the Internet to cancel dinner with friends and then backed it up with a text message for extra effect... I use my computer for most things. Thanks to the Internet, I have been able to redecorate our bedroom, spare room and hallway, complete with wallpaper and carpeting without ever leaving the comfort of the couch I bought on eBay. I have spent more time shopping in cyberspace than most people do in a mall and rejoice in my lap top's ability to support my need to multitask at all times. I stand firmly in the belief that MY Internet has not only made me smarter but more efficient. Give me a WiFi connection, a cup of coffee and 45 minutes and I think I can make magic. However, the Internet, like accessories can be very dangerous when put in the wrong hands. I believe cyberspace was invented for three basic things...

The exchange of ideasShoppingPorn

I draw the line at self diagnosis. Mother if you are reading this.... do not shut off your computer. I regularly have patients present to my office with a list of their symptoms and a list of possible diagnoses, only to tell me what they have "come up with" as far as the Internet is concerned. Make no mistake, I am all for patient empowerment and people being a part of the healing process. i am a firm believer that a patient is best served when the treatment process is a team effort. That team, however does not include some My Space with a need to diagnose perfect strangers.

I can't help but think it is a sad reflection on how we as physicians have lost touch with our patients. We've have gotten so overwhelmed by the disease and the work that we forgot how to just sit and talk to people. Maybe it's because we are working too hard. Maybe it is because there is more disease and more treatment than ever before in our profession. Maybe it is easier to give someone a website and the name of their disease and let them "have at it".

I'm all for people learning about treatment options and what lays before them once they have been diagnosed with an illness. BUT, last week a woman walked into my office and told me she had used the Internet to diagnose herself with Addison's Disease, an illness where your adrenal glands don't make enough stress hormones. She had been fatigued for sometime and had gone on several websites and entered her symptoms and POOF! There it was... her diagnosis. Furthermore, she had been able with a few clicks to send away for steroids and was now going to start treatment. I kid you not.

Needless to say, I did screen this woman for Addison's and she does not have the disease. I spent an hour trying to reassure her that she did not have Addison's and I would not be surprised if she is still taking her cyberspace steroids. This is not meant as a cautionary tale. I know this is an EXTREME case, but it is there. Internet connections are like children.... A fever is not Swine flu until proven otherwise and a headache is often just a headache. I'm a huge fan of people taking their own blood pressure and keeping a list of their own medications. This is not about self-breast exams. I am talking about googling symptoms and coming up with a diagnosis (you know who you are). My mother, and I do love her, Diagnoses herself all the time. She often seeks a second opinion through the help of friends who have similar symptoms. So, I had to know.... what is the evidence behind self diagnosis?

According to a 2008 research report by Microsoft concerning the escalation of medical concerns in web searches, of the 8 in 10 American adults that have searched for health care information online, “75 percent refrain from checking key quality indicators such as the validity of the source and the creation date of medical information”. A recent report by the BBC says that by 2020, 35% of people will use the Internet to diagnose their ailments. Furthermore, a study published in the Journal of the American Medical Association Looked at the accuracy of people searching for medical information online. The study surveyed over 15,000 people searching for medical information online looking at the accuracy, completeness and design of health-related websites. It showed that in 70 percent of the studies examined, the quality of health-related Web content was low at best.

So, if 80% of people search the web for medical information and only 30% of them get descent advice, That leaves 6 out of 10 people thinking they know more than they really do... The story rings as loudly as ever. Sure, search the net- but BACK IT UP! We should be talking to a doctor for medical concerns. I have yet to hear of people fixing their cars with only online help... So for all my cyber sisters out there... Don't take my word for it! Before we go any further... please don't use me for diagnosis. I am merely a weekly amusement. I may be a stylish dresser and a witty woman, but I am also most certainly full of shit. That is unless you are a patient in my office and then, yes, like all doctors... I DO know everything.

Monday, September 21, 2009

It has recently come to my attention that I spend a small country's Gross National Product on coffee and I am not alone. This became ever apparent when my beloved home grind and brew machine ground to a halt, so to speak and I have decided NOT to replace it. We live in downtown Vancouver. There are more coffee shops in our area than there are trees and we have the largest rain forest north of the Equator just a short 10 minute walk away. This is not a proud statement about the times we live in, no judgement here people, just truth. I can chose from Starbucks, Tim Hortons, Artigiano's (phenomonal lattés BTW- not a plug but a fact), BLENZ, WAVES, The Wicked Cafe and the list goes on. I could sustain a caffeine high for 14 hours a day without ever using the same coffee shop twice, all without leaving the comfort of my 20 block radius.

I am not complaining. I am quite pleased with my current coffee situation. I like not having a coffee maker. It takes up a great deal of counter space, it needs to be cleaned and cared for and most importantly I make shitty coffee. I'd like to think I have a modicum of other talents, being a barista is not one of them. I can never get the coffee to water ratio right. Is it a one scoop to one cup thing? Does this vary according to blend of coffee? I have been told by many that I need to use distilled water and the right beans but have failed to pursue any of this. It is far too much work for my true drug of choice. And so as any fiercely independent woman would do in this situation, I have donated my old coffee maker to Salvation Army and now rely on someone else to make my coffee for me.

It has been over six months into my "Don't do it yourself" venture and it has dawned on me that I am racking up quite a bill. Shockingly, I am NOT a fancy coffee girl. I prefer a good, plain, large drip coffee. The occasional low fat latté is a bit of treat but only when I can sit in a café and drink it like a civilized person while the world passes by. Otherwise for my Daily Fix I prefer a standard mild blend. This has of course been financially advantageous but nonetheless, I am spending upwards of $2-$4 per day (depending on the amount of work I need to get done) on coffee. I justify my $1500 a year habit with the usual "I work hard, I deserve it", that many of us will use to justify anything worth purchasing. Every now and then it dawns on me that if I gave up the caffeine ghost I could broaden my shoe closet? In fact as I sit in my local café, espresso coursing through my veins, trying desperately to be witty for just one more week, i am painfully aware that Italian drink to my left is impeding my ability to enjoy the true gifts the Italians have given to society... expensive footwear.

Apart from my footwear realization it has also come to my attention among my java journeys that coffee is truly a personal choice. One's coffee choice is one's fingerprint on life. I am a "Venti Mild blend, 2 fingers of cream with 4 artificial sweeteners" or as I like to call it. "Venti mild, Skinny with legs". My husband prefers an Artigiano Machiatto (I still have no idea what is in it). My friend "K" is a die hard for a good Tim Horton's double-double. Our coffee choice is as much a personal statement as is our choice of car, bank, hair colour or religious affiliation. We develop it over time and stick with it almost militantly. It is our little declaration to the world about who we are. For example, people who use travel mugs care about the environment and like their coffee very hot. Low fat choices declare one's interest in healthier choices and one's overall high maintenance. In my experience people who like Mocha's are embracing their inner child and those with a taste for an Americanno have really good taste in handbags. There is no science to this- it is purely speculation on my part.

Where there IS science, thankfully is in the health benefits to coffee drinking. Firstly, the average cup of coffee contains about 200 milligrams of caffeine. In short it is about 2% caffeine, 98% "other stuff". It is likely that other stuff that offers it some benefit. There is an overwhelming amount of observational studies showing a benefit of coffee consumption of 1-4 cups per day to reducing Parkinson's and Diabetes. Twenty studies worldwide show that coffee, both regular and decaf, lowers the risk for Type 2 diabetes, in some studies by as much as 50%. Researchers out of Harvard University say that is probably because chlorogenic acid, one of the many ingredients in coffee, slows uptake of glucose (sugar) from the intestines. (Excess sugar in the blood is a hallmark of diabetes.) Chlorogenic acid may also stimulate GLP-1, a chemical that boosts insulin, the hormone that escorts sugar from the blood into cells. Yet another ingredient, trigonelline, a precursor to vitamin B3, may help slow glucose absorption. The take home message here is that a drink once thought to cause harm may even be helpful!

And so always a fan of science, another day, another four dollars. I finish my cup and this weeks' Girlfriend's Guide with the knowledge that life is about choices. I choose to leave my coffee in the hands of those who have the proper respect for the bean. I choose my Venti with cream and chemicals in the hope that all those antioxidants will cancel out whatever crap I put in the coffee in the first place. I order my coffee, make my personal statement about who I am and what I want and move on into the world knowing I may have prevented disease with yet another cup. Am I drinking coffee to PREVENT Diabetes? No. That is what healthy eating and exercise is for. But at least I can justify my $1500 a year as a health expense. After all, health really is priceless. My next mission is to find a study showing that Manolo Blahniks are good for your cholesterol.

Monday, September 14, 2009

My beloved is a geek. Not the old school kind with pocket protectors, coke bottle glasses and a "Revenge of the Nerds" laugh. He does however have an almost romantic connection to his computer and as for video games? They are not only his source of income but a true life force. He works as a technical artist for Relic Entertainment, a video game company. At many a party he is the coolest "dude" in the room. When asked of my career many people respond with a longing look as if to say "will you be my family doctor?' To which I respond "I am not family doctor" and the conversation is over. Jason, however, when asked of his job inspires many a man to become a boy again. Nobody wants to play doctor anymore.... they all want to play real time strategy (RTS) with Role Playing Game (RPG). Throw in a little MMO (Massive Multiplayer Online) and my ability to prescribe narcotics can no longer compete with the degree of this sexiness. I always thought it was awesome that our careers were so vaslty different. And really unless he had a game that was making people have seizures our two career paths would not likely converge.

First, as always, there is the fashion. Jason's uniform is a t-shirt either with some recent alien having its head blown from its face or a hoody in praise of a war time stretegy game which allows every twenty year old to kill a Nazi from the comfort of his/her own living room. I like my fashion more off the runways where he goes to work as a marketing statement mixed with just the right pair of jeans and shoes which are funky because they were bought by his wife.

Make no mistake, I am so proud of his work and his passion for his craft. Rarely will one meet someone who TRULY loves his/her job and much as my beloved. But I never thought HIS work would change mine. That was until last week.

I was waiting for my next patient in clinic. I have changed some of the features of her case to keep things confidential, of course. She was seeing me for high cholesterol and her 19-year-old son came with her to the appointment and was waiting in the waiting room as well. I went out to the room to get her (we'll call her Debbie, although this was not her name) and sitting next to her was her son "ZacK" (not his real name). She was reading one of the shitty magazines I encourage my patients to steel from my office, Zack was reading World War Z by Max Brooks. I am not entirely farmilar with the book only to say it is the Warren Commision equivalent in the event of a Zombie attack. It sits on my husband's bedside table and he talks of it with as much respect as I do British Vogue. I do know that it is by the same author as the Zombie Survival Guide and incidently Mel Brooks's son.

So as charming as ever I said to my patient's son,

Good Book? I hear it is almost like a 911 investigation into the Zombie wars." He looks up at me with awe. "Have you read it?" he asks."No, " I reply, "but my husband is really into that stuff. In fact have you seen the movie District 9? I just saw it last week... great film.""I am going to it tonight" he says almost in a whisper. "You will love it> "He was dumbstruck. And as if that is not enough, I take out my light-saber and issue one final geeky blow."I can't wait to see AVATAR in December. I hear there was a 25 minute clip at comic-con this year that was amazing. 310 million on a movie.... better be worth it." I say with confidence.

Make no mistake, I really did like District 9. In fact, I like it more than my husband did. I also am looking forward to seeing was 310 million dollars will buy you in a movie these days. I was not just feeding this 19 year old a line, I was, however embellishing my "Geek Mystique" learned, nay, absorbed from years of living with a "Tech-E Monster" in order to further my patient-physican relationship. "How do you know all this?", Zack asked in wonder"My husband does FX for a video game company" I replyIt turned out that Zack's favorite game was the one my husband worked on and I told Zack. A five minute conversation had cemented me as this geeks new Wonder Woman, complete with laso of truth and fabuous wrist bracelets."You my Mom's Doctor?" he asked."yes" I smiled"Wow..."

Zack and his mother came into my office and so began a long debate about whether this woman who had high cholesterol and had already had one angioplasty would take her cholesterol medications. I was ready for a head to head throw down ahead of me. I would quote statistics, the benefits of secondary prevention and give her the evidence on a silver platter. I was ready. But before I could intervene her son put down his book and calmly said to his mom, "Mom she totally knows what she is talking about. You really should listen. You've already had one heart attack, you don't want another."

From then on it was like a dream. I wrote a prescription for a cholesterol medication and SHE TOOK IT! No messy talk, no power struggle. No quoting studies, no proving how much I knew. I was a monkey who did not need to dance! WHY? Not because I was a strong, intelligent, accomplished and trusted physician. No, 9 years of clinical practice had not given me shit in this situation. I had clinical credibility right then and there. Thousands of hours spent studying and in conferences were reduced down to the simple fact that I knew what RTS (real time strategy) stood for. It did not matter that secondary prevention with statins reduces cardiovascular events further as much as 50%. What mattered was that I knew what World of Warcraft was and I was sleeping with the guy who was doing the technical art on Spacemarine.

This got me thinking about what makes a patient trust a physician? What makes any of us trust any authority figure at all? Had I not known the ins and outs of the gaming world, would Debbie leave her diagnosis to Google? Science has some evidence to suggest that a patient remembers only 50% of what a patient tells them. In fact several studies both in the New England Journal of Medicine and in the American Journal of Psychology suggest that a patient's compliance rest in their relationship with their doctor long term and in other social factors such as their family make-up and whether they have had a bad experience in the past. This all seems logical to me, the fact is there is evidence to back it up.

Today, however, science begone, tonight a gamer and not a doctor was king. And so life in that instant became a video game itself. In the battle to save the universe my avatar was not a 39 year old doctor with great hair, logical arguments and a killer shoe closet. No I was "game-boys" wife; with Wonderwoman hair and just enough knowledge of the geek to get one young man to convince his mother to take a potentially life saving drug. There was all the drama of World of Warcraft and Gray's Anatomy was nowhere to be found. And when I arrived home that night and kissed Jason on the cheek. I realized how much I had to be grateful to the geek. For although there are days where I mock his laptop in bed or the fact that he is physically attached to an ipod at all times, today would not be one of them. I often joke that I send a 35 year old man to work every morning only to have him come back as 16 year old boy each day. Today, however, was a revelation. Today, Jason sent a 38 year old doctor off to work and she returned home a Superhero. And so dear reader, today was the day, where video saved the medicine star...

Monday, September 7, 2009

This Labour Day, I let more than 400 people with less than 10% body fat pass me by. Truth be told it may have been more than 400 hundred, I lost count somewhere around the 357 mark. It was the Vancouver Triathlon – Sprint Distance and I had a point to prove. I am not sure to whom this point was proven but now muscles aching, calories burnt and the best post race brunch I have had in a long time I am glad I did it. To top it all off, The New England Journal of Medicine says I will live longer.

I am not one of those people who instantly gets the “runners high”. In fact four years into running, I am still waiting for anything other than pain and the guilt free consumption of carbohydrates to occur after any exercise. I am not complaining. Nor am I minimizing it to make my lazier friends feel better. Triathlons are physically, mentally and fashionably a challenge. To begin with there is the obvious commitment of at least an hour or two a day to all three sports; swimming, cycling and running. You train constantly. Fortunately the activities to chose from (cycling, swimming and running) are varied enough to banish away any boredom of doing the same thing day in and day out. On race day there is still the challenge of 750 metres of swimming in the ocean, a 20 km ride through Stanley Park followed by a 5 km run. It truly is the axis of evil.

Mentally there is no other battle like it. Let us begin on the shores of Second Beach where at 6:45 in the morning I realized the water was a breezy 14 degrees Celsius. Regardless of a wet suit and all my formative years spent in Winnipeg, Manitoba, this would be cold by all standards. After my “practice swim” in the ocean lasting only 10 minutes, my face grew numb, my left foot froze and my resolve grew firm. I would finish this bullshit if it killed me. Sixty minutes later the starter horn sounded and I along with several hundred of my crazy sisters threw ourselves into the ocean for twenty minutes of sheer exhilaration and terror. It was ice and salt and fear and fabulous.

When I leave the water there is a run up the beach to the transition zone, where the cold and the dread melt away as perfect strangers cheer on my victory and in that moment I feel like a rock star. In the transition zone, I collect my bike, run to the start of the cycling course and I am off for twenty kilometers through the best rainforest north of the equator. It was on this ride that I have time to let my mind wander. I mentally clean out my closet, at least twice, virtually write this article in my head, and figure out what I will wear tomorrow as the world falls away in the fifty minutes I spend alone with my thoughts. Whizzing by me is every four thousand dollar Cervelo bike (The Porche of Cycling) and on it a phenomenal display of the human form. I am not embellishing when I say that in the span of 20 kilometres I must have seen more muscles than I did in a year of Anatomy class.

Finally the race ends with a 5 kilometre run that really is like having a salt bath after being sand blasted. Everywhere you have skin you have pain and mentally you do everything in your power to just “be in the moment” and “visualize the finish”. If not for the volunteers and spectators cheering me on I would have sat down midcourse for a latte and a nap. These are the physical and the mental hurdles that face us all in any of life’s races. But in triathlons there is the added concern of the fashion challenge. As my readers know, I do love the gear. I am not a sporty girl but any activity that allows for an outfit deserves at least give an honest effort.

Triathlons are the quintessential “gear sport”. You have to respect a sport that allows for two costume changes. First there is a wetsuit, which really is a superhero costume. Rarely is neoprene a fabric worthy of praise but apart from keeping me relatively warm at 14 degrees, it truly is the best body lift money can buy. If the suits were thinner and more functional, I would take one in every colour. After emerging from the water the wetsuit is stripped of in the transition zone and I essentially get naked in front of hundreds of strangers.

This is one of the reasons I have dubbed triathlons "the naked sport". Essentially it is a group of insanely fit people with 8% body fat wearing almost no clothing running around from sport to sport in their underwear for several hours. As for me, I am in a racing bra and cycling shorts but I am soaking wet and a bit chubby- this is not a good look for me. I am however shameless or brave, depending on the audience, as I put on my cycling jacket and my cycling shoes. It is a magical costume change that is seconded only by the running outfit that follows. A headband replaces my cycling helmet, the cycling shoes with runners. The true challenge of triathlons really is not the multiple sports but the ability to remain fresh looking at the finish line after several hours, three outfits, an ocean swim and a wicked case of helmet head. Master this and one can rule the world.

And so master it I did, with a smile on my face and a song in my heart. Despite the pain, the cold and the preponderance of “wet spots”, it truly was a glorious was to spend a morning. Always one to challenge my brain, it was a nice twist to challenge myself from the neck down, and to see just what I was made of.

My best friend in Toronto has taken up running. She has two kids, a full time job and easily 500 better things to do with her time. But every morning she gets up at an ungodly hour to meet the dawn and the neighbours for forty plus minutes of a walk/run. She tells me I’ve inspired her with my newfound fitness madness but I truly think it’s become a mutual inspiration. Here I am on one side of the country, swimming, riding or running and there she is on the other with a group of mothers trying to get their fitness in before the madness of their day begins. The polarity of this has never been clearer and yet in my mind it has brought us closer together.

The Nurses Health Study (NHS) is the largest and longest study to date looking at women and risk factors for heart disease. The NHS began in 1976 and to date has followed over 276,000 adult women aged 27 to 44 years. One aspect of the NHS by Dr. Frank Hu and colleagues examined the association between exercise and risk of death among women in the Nurses' Health Study over a 24-year period. The study was published in the New England Journal of Medicine in December, 2004 and showed that women who exercise more than three and a half hours a week have almost half the risk of cardiac death independent of body size than those who exercise less than an hour a week.

I am sure there are days where my friend in Toronto wants to hit the snooze button until it breaks, but she doesn’t (and after reading this she most certainly won’t). There are days for me, when the water is too cold, the road too long, my butt too sore. But a long and healthy life is like anything worth fighting for. It may not be a series of maddening exercises through water wind and fire, so to speak. It may come down to an early morning power walk with the local PTA. As I rode those twenty kilometers through Stanley Park on Labour Day morning, I mentally removed the white from closet and had a little mental connection with my BFF in Toronto, we'll call her "K". In those moments alone with my thoughts and the hundreds of naked muscles whizzing by me on overpriced cycling machines, I was inspired; by the fabulous commitment of the people around me, by a mother of two somewhere in Toronto who was likely finished her morning power walk and sitting down to eat breakfast with her family. Mostly, I was just inspired to spend the coming winter months training for the next great race, when I will endure the madness and the monotony all over again and all for the perfect costume change.

So forgive my indulgence, dear reader, never one to “play favorites”, but this one’s for “K” wherever she may be. Thanks for making me your “inspiration”. According to the evidence, we're both likely to live a little longer despite the fact that most times when I exercise I feel like I’m dying. And here is to you, my dear friend, post this Labour day.... May our outfits be fabulous (even if they are white) and may we both hit the snooze button a little less often…

About Me

Dr. Ali Zentner received her undergraduate medical degree from McMaster University and completed her Internal Medicine Residency with an extra year of Cardiology training at the University of Calgary. Ali has been practicing Internal Medicine since 2001 as a specialist in Cardiac Risk Management and Obesity. Ali is the author of The Weight Loss Prescription, published by Penguin books in 2013. It is the ultimate guide for healthy living and one hell of a book (no bias here). Ali also wrote A Good Life, a work of fiction, published in 2003. The novel has been best described as “Sex in the City” meets “ER” and details one woman’s struggle to find meaning in a world not always under her control. Both books are available on amazon.com. A classic overachiever, Dr. Zentner has completed the Vancouver marathon, and half marathons in New York, Vancouver and Toronto. She is an avid swimmer, runner and cyclist training for her next triathlon and who exercises to keep fit and to justify her next fashion purchase. She lives in Vancouver with her husband who says nothing about the size of his wife’s shoe closet (if he knows what is good for him)…